Are you ready for a maxillofacial post? One dentist's experience

Blog Author
Shaadi Manouchehri

Blog Date
19/02/2018

Page Content

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The short answer is no.

And the long answer is definitely no.

Before starting my rotation, maxillofacial surgery always struck me as a peculiar specialty where medicine and dentistry were combined, and there was somehow no conflict or confusion over whether we could refer to ourselves as doctors or not.

But nothing, and I mean nothing, no courses or handbooks or pep talks could have prepared me for what I was about to go through.

We have all, as practicing dentists, read the resuscitation guidelines on medical emergencies in dental practices and know about the signs and symptoms of anaphylaxis and its management.

However, when you receive that first alarming call and you are told that your patient is in the resuscitation room (resus), all your knowledge and preparations would suddenly vanish, leaving you at the mercy of the situation.

Your number one priority becomes avoiding fainting and becoming a medical emergency yourself because you know they will be busy in resus and you do not want to be the junior doctor whose only involvement in the situation was to occupy the bed next to the patient with the cardiac arrest.

That is not what they meant when they taught us about 'sympathising with the patient', as an undergraduate.

Thrown in at the deep end is an understatement. More like thrown out of a plane at an altitude of 20,000 feet without a parachute. But you do learn to fly, metaphorically speaking, mainly because there is no alternative.

New concepts

As DCTs, we are used to clinics and dental hospitals but rarely a District General Hospital environment.

Everything seems much more fast-paced and intimidating. Being in majors for the first time makes you feel like you are a pedestrian in the middle of a busy motorway or a civilian in the middle of a warzone.

You may find yourself feeling small and vulnerable. That is, until you realise that A&E doctors cannot interpret an OPG, which is when you begin to gain confidence in your own abilities.

Your BDS is not to be underestimated. Your manual dexterity and fine surgical skills can come in very handy in attending to facial injuries and managing traumatised dentition.

Another concept to familiarise yourself with is that every day is potentially a work day. Bank holidays, nights and weekends no longer apply to you. A fact that your non-medical friends and family will struggle to come to terms with, regardless of how many times you remind them.

Being on call

For me, being on-call was the most challenging aspect of the job. Our medically qualified colleagues are familiar with the concept of being available for long periods in case they are needed, but as newly-qualified DCT, this phenomenon is totally new to us.

Being on-call normally consists of 12 hours of continuous palpitations, hoping that your bleep does not go off and your heart skipping multiple beats when it does.

Any specialty in the hospital could consult us for maxillofacial input or alternatively clinicians outside the hospital could call us for advice. Initially most cases seem new and challenging, however as you become accustomed to the various maxillofacial cases, you begin to understand which cases would benefit from maxillofacial input and which ones would best be suited to other specialties.

Ear, nose and throat (ENT) for example is a specialty that we work closely with. Occasionally there may be overlap of cases that we treat and confusion as to which specialty should accept the patient.

This may sometimes depend on your workload as on a quiet day you may accept a laceration on the tragus of the ear, whereas on a busy day you may direct the case towards ENT. Different hospitals and trusts may have different protocols regarding this.

Handover is also something that is new. You receive a handover from the person on-call before you and you handover to the person on-call after you. A handover is essentially a concise update of what has been happening on that shift and an opportunity to pass over any outstanding jobs.

It is very important to have a smooth and concise handover ensuring all outstanding jobs are highlighted and none are "lost in transit". Some shifts may be more chaotic than others and it is our responsibility to ensure that the handover does not suffer as a consequence. Always make sure you are on time for handovers and bear in mind that the person covering the night shift has not slept! So try and be compassionate.

The cases that are referred to us can be very diverse. It could be an extensive laceration, a dental abscess, a sebaceous cyst or fractured facial bones. You need to ascertain whether the patient needs to be admitted or if it is safe for them to be discharged following treatment. Always discuss with your senior if you are unsure. A submandibular swelling for example may require admission if there is a risk of airway compromise, however in less severe cases the patient may be able to go home with oral antibiotics.

Top tips

Take care of yourself on long shifts: It is very easy to forget your basic human needs when looking out for that of your patients. Remember to stop and assess your own vital signs occasionally. It is very likely that you will become overwhelmed by all the outstanding jobs and the patients waiting for you in A&E, but remember to stop and rest, and maybe even eat something once in a while. The moment you start to ignore your own situation and exert yourself, you start making mistakes which could drastically affect you patient care.

Make sure you have the full picture before accepting a patient. It is very tempting to run to A&E to assess the patient as soon as you receive a referral. As you become more experienced, you will become more conscientious when accepting referrals. Make sure you take a full history and that the patient is stable before you accept them. If there is a history of assault or trauma, make sure the patient is cleared of a head injury first. The last thing you want is for the patient to become acutely unwell due to an intracranial haemorrhage that was missed as you are attending to their superficial facial injuries. In the vast majority of cases, the maxillofacial input can be delayed until the patient is declared haemodynamically stable.

Ensure you ask for all relevant tests to be done before assessing the patient: these can include observations, bloods and radiographs.

Be kind and polite to the nurses. They can make things very easy or very difficult for you depending on how you treat them. On a busy shift, it really makes a difference if the nurses help you by taking blood, administer your treatments in a timely manner and help you with managing your patients.

Resist the urge to become overwhelmed. Easier said than done, I know. Take each case step by step and tackle it systematically. This will make your life a lot easier.

Do not compare yourself to others and do not become disheartened at your own perceived inexperience. Everybody in your team will have a different level of maxillofacial experience. Use it to your advantage and learn from those who are more experienced.

Remember that you are in a training post. Try and be pro-active and direct the training if you have to. Ask to be shown how to carry out procedures and volunteer to do these. Operating theatres are great places to learn and practice. So ask your seniors if it would be ok for you to carry out that procedure, impress them, gain their trust, and hopefully next time they will trust you to do it.

Identify your own reason(s) for embarking on your maxillofacial journey. It may be that the maxillofacial pathway beyond this year is not for you, in which case make sure you make the most of this year, as you may not get a chance like this again.

Challenges

As you may have already gathered, this year has not been without its challenges for me. There have been many times when I have stopped to re-assess my life choices.

Times where I have left the house before sunrise as my family sleeps peacefully and times when I come home after they are all sound asleep. Times when I have been the first to arrive in the multi-story car-park and amongst the last to leave as I hear rumours of "no parking spaces left" during the day.

Times when I have fainted in theatre (luckily not over the patient…yet) and times when I have spent endless hours retracting and suctioning only to be told I am doing it wrong.

Times when I have realised there is a right and wrong way of suctioning. And that time when my patient in A&E was more concerned about my wellbeing than his fractured mandible saying I look much more unwell than he does.

Despite all of this, there have also been times where I truly felt I had made a difference to a patient's quality of life. Patients presenting to A&E are amongst those who are most distressed and commonly attend with their loved ones who are also very concerned. It can be a very humbling experience to address their concerns and provide necessary treatment to alleviate their symptoms.

Final thoughts

As with many things, there are positive aspects alongside the negatives. Despite all the challenges, this has been an incredibly rewarding year. You will grow in strength, both mentally and physically. You will learn a great deal about team work and hospital dynamics. And the skills you acquire are transferrable to almost any other post you would undertake in the future.

No matter where life takes you, at least you will be able to say: "I survived a year in Maxfax".